Quality Indicators and the relevance of Indicators in General Practice: How to conceive and execute?

Friday, April 5th, 2019

Eva Arvidsson

MD, PhD, Specialist in Family Medicine,

Research leader, R&D unit for Primary Care, Futurum, Region Jönköping, SWEDEN

EQuiP

Outline

• Quality indicators, introduction

• External use

• Internal use

• Example: Primary health care in Sweden

An indicator, NOT a measure of quality

A simplified, measurable dimension of a more complex phenomenon.Not reality - A starting point for discussions about reality.

Quality indicator

Percentage of asthma patients who have been seeking acute for the past 12 months due to asthma

Percentage of asthma patients examined with spirometry in the last 24 months

Quality indicators

External use• Accountability

• Control, Judgement, Ranking

• Distribution of resources• Planning health care

Internal use

• Quality Improvement• Distribution of resources

• at practice level

Top down

• By health care authorities

Bottom up

• By professionals Show primary care’s results and needs

Swedish project

Pay-for-performance (P4P)

Pay-for-performance (P4P) -Better than present system?

• Internal: Find areas for improvement, i.e. weaknesses in performanceExternal: Hide weaknesses - ↓ local needs for improvement

• Health professionals’ motivation from • intrinsic (wanting to do a good job) to • extrinsic (getting rewarded)

• Focus only on goals that are payed • Other goals neglected• Worse after payment ended

• Documentation – gathering data for P4P indicators Consultations ↓ patient's agenda and purpose

• Results from better documentation > better outcomes for patients

• Yuan et.al: Cochrane review, 2017• Slight improvement in use of tests or treatments• Little or no improvement in health outcomes

REFERENCES: Yuan B, He L, Meng Q, et al. Payment methods for outpatient care facilities. Cochrane Database Syst Rev. 2017 Mar 03;3Campbell SM, Reeves D, KontopantelisE, et al. Effects of pay for performance on the quality of primary care in England. N Engl J Med. 2009 Jul 23;361(4):368-78. 10.Petersen LA, Woodard LD, Urech T, et al. Does pay-for-performance improve the quality of health care? Annals of internal medicine. 2006 Aug 15;145(4):265-72. 1Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev. 2006 Apr;63(2):135-57. Campbell SM, McDonald R, Lester H. The experience of pay for performance in English family practice: a qualitative study. Ann Fam Med. 2008 May-Jun;6(3):228-34. Maisey S, Steel N, Marsh R, et al. Effects of payment for performance in primary care: qualitative interview study. Journal of health services research & policy. 2008 Jul;13(3):133-9. Mannion R. Take the money and run: the challenges of designing and evaluating financial incentives in healthcare; Comment on "Paying for performance in healthcare organisations". Int J Health Policy Manag. 2014 Feb;2(2):95-6.

EQuiP: Position Paper on Quailty Indicators

7

Internal use

Quality improvement

External use

Control

Pay for Performance (P4P)

!

Internal use – Indicators by professionals

• Quality improvement • What do we need to improve?

• How can it be measured?

• Shared /public indicators• Compare with each other

• Follow/monitor

• Show stakeholders what we do

Donabedian A. Evaluating the quality of medical care. 1966, Milbank Q. 2005;83(4):691-729.c

Constructing indicators - by professionals

Topic? Relevant? Important?Validity: High score = better care? (Evidence? Consensus?)

In control of the GP-practice?Necessary to document?

Staff, Equipment

What we do in health care

Results

Structure Process Outcome

Balancing measurementsOther aspects?Other patients?Health professionals?

Primary Care Quality Sweden

• Purpose: Quality Improvement

• Initiated by Swedish College of General Practice 1990, Financed from 2012• Manual Digital

• Indicators: • Around 100 national primary care indicators• Evidence based knowledge• Constructed and tested by professionals in primary care• Multi-professional (Professional organizations)

• Practice level: Individual patients

• Aggregated data from all Sweden for bench-marking

Primary Care Quality Sweden

• Purpose: Quality Improvement

• Initiated by Swedish College of General Practice 1990, Financed from 2012• Manual Digital

• Indicators: • Around 100 national primary care indicators• Evidence based knowledge• Constructed and tested by professionals in primary care• Multi-professional (Professional organizations)

• Practice level: Individual patients

• Aggregated data from all Sweden for bench-marking

Primary care specific IndicatorsMultimorbidityContinuityPriority settingLifestyle habitsDrug treatment

Diagnosis specificIndicatorsCardiovascular diseaseDiabetesMusculoskelettal diseasePsychiatric diseaseAsthma/COPDOsteoarthritisInfections

Patient reportedindicators

Example of Indicator in “Primary Care Quality Sweden” Overdiagnosis: ”Lagom” Prevalence

AnxietyBothDepression

Prevalence of Depression and Anxiety per population registered at each health centre, 20-79 years

%

HC

3H

C 2

HC

1

LAGOM

Not too little, not too much.

Just right.

Overtreatment: ”Lagom” medication!

Infections: treatment with antibioticsRespiratory tract infections, % treated with antibiotics % recommended class of antibiotics

Example of Indicator in “Primary Care Quality Sweden”:Care according to needs/Equity: Finding patients in need

No visit last yearNurseGP and nurseGP

Avoid “loosing” patients – Check-ups for COPD patients, with medication

HC

3H

C2

HC

1

Joy at work

• Orderliness - everybody works as agreed on

• Appointed persons responsible for follow-up and development of different areas of activity

• Scheduled time allocated to discuss how we actually handle our patients

Thank you!

Eva Arvidsson evaarv@gmail.com

Primary Care Quality Sweden - SKLhttps://skl.se/tjanster/englishpages/activities/primarycarequality.10073.html